Although perceptions of internal control have been related to physical and psychosocia1 outcomes in chronic illness, less attention has been paid to perceptions of external sources of control and their implications for adaptation. One reason for this has been the dearth of adequate measures for assessing specific external control constructs.

The God Locus of Health Control (G L H C ) scale was developed to assess the extent of an individual's belief that God controls his or her health status. The G L H C was designed as an adjunct to the widely used Multidimensional Health Locus of Control ( M H L C ) scales. Initial studies of the psychometric properties of the G L H C scale in samples of persons with two rheumatic diseases, rheumatoid arthritis and systemic sclerosis, provide evidence of the scale's reliability and validity.

K E Y WORDS: control; religion; health; illness; measurement.

The positive and negative consequences of seeking and gaining control over life events has been systematically studied by psychologists since the late 1960s (Shapiro, Schwartz, & Astin, 1996). Control-related cognitions have been examined in numerous contexts, including both mental and physical health and illness. Within the context of physical illness, substantial literature exists supporting the importance of health-related control beliefs to both physical and psychological adjustment. A sense of personal control has been related to positive outcome in individuals with physical illness; generally, a large body of research has shown that those who believe that there are ways of exercising control over their illness or related circumstances 'Vanderbilt University.

2San Diego State University, San Diego, California.

'SDSUIUCSD Joint Doctoral Program in Clinical Psychology.

4Peabody College of Vanderbilt University.

'Nashville, Tennessee.

'UCSD School of Medicine.

'UCLA School of Medicine.

'Requests for reprints should be addressed to Ken Wallston, Ph.D., School of Nursing, Vanderbilt University, Nashville, Tennessee 37240.

have more positive psychological and physical adaptation than those who do not (Affleck, Tennen, Pfeiffer, & Fifield, 1987; Shapiro e t al., 1996).

Many of these studies have focused primarily on perceptions of internal control in relation to adaptation to illness, despite the long-established validity of conceptualizing control as multidimensional (Shapiro e t al., 1996; Wallston, 1989). Shapiro et al. (1996) suggest that, in particular, beliefs andlor cognitions that focus on external sources or agents of control have received far less attention.

One notable exception to this is the measurement approach underlying the Multidimensional Health Locus of Control (MHLC) scales developed by Wallston and colleagues (Wallston, Wallston, & DeVellis, 1978). The MHLC originally contained three subscales describing various types of control-related cognitions

an individual may have about his or her current state of health. These were:

Internal Health Locus of Control (IHLC); Powerful Others Health Locus of Control (PHLC); and Chance Health Locus of Control (CHLC). The two original versions of the MHLC (Forms A and B) deal with general health status, whereas a third version, Form C (Wallston, Stein, & Smith, 1994) assesses control-related cognitions about a specific disease state. The psychometric properties and practical utility of the MHLC scales have been established in hundreds of studies since the 1970s (see Wallston, 1989), including a number of studies of adaptation to chronic illness. Among the more important findings emerging from this literature is that internal and external control perceptions are differentially related to physical and psychosocial outcomes in chronic illness (Wallston, 1989). This underscores the need for a more fine-grained analysis of people's cognitions about various external sources of control over illness.

One external source of health control that has not received sufficient attention is that of religion or "Supreme Beings" such as God. Based on surveys of adults in the United States, 94% believe in God, 90% pray to God, and a majority actively practice their religion (Park & Cohen, 1992). It seems likely that religion may be a source of control-related cognitions. However, to date, religiously based healthrelated control beliefs have received little attention. One central reason for this lack of research study has been a dearth of measurement tools. In 1996, an intial effort was made to expand the MHLC to include a construct termed "God control" (Welton, Adkins, Ingle, & Dixon, 1996). Welton e t al. wrote six new items for insertion into the general (non-condition-specific) health form of the MHLC, modified the response format, and administered the new scale to two samples of healthy undergraduates. The new scale was internally consistent, positively related to religiosity, and generally uncorrelated with the other MHLC subscales. G o d healthcontrol beliefs predicted general health habits in one of the two undergraduate samples, but were unrelated in the other.

The modification of the general form of the MHLC made by Welton et al. is a useful step in the development of tools for assessing religiously based health control beliefs. However, to date, there has still been no scale available to assess this construct in people who have acute or chronic health conditions. The purpose of this paper is to describe expansion of the MHLC Form C (specific disease state) to include a new subscale: God Locus of Health Control (GLHC). This scale is designed to assess the extent of the belief that God exerts control over one's current God Locus of Health Control disease state9. The G L H C consists of six items and is similar in format to the other MHLC scales. The purpose of this paper is to introduce the G L H C and present psychometric data drawn from three samples of individuals with two different rheumatic diseases, specifically rheumatoid arthritis ( R A ) and systemic sclerosis (SSc).

METHOD

Participants Rheumatoid Arthritis Two independent samples of persons with a confirmed diagnosis of RA participated in this study. RA is a systemic autoimmune disease that involves the chronic and painful inflammation of the joints. However, the pain varies greatly over time, and for many the disease is characterized by unpredictable periods of remission and exacerbation; R A can be quiescent and then "flare" without warning into a bout of intense pain (Brown, Wallston, & Nicassio, 1989; Skevington, 1987). When flares are frequent or of long duration, the results often include disfigurement, fatigue, and loss of functional ability. The net result is that more than 50% of R A patients suffer significant work disability within 5-10 years of disease onset (Canosco, 1997; Yelin, Meenan, Nevitt, & Epstein, 1980). There is no cure for R A, and most treatments are only marginally and temporarily effective. However, although associated with significant side effects, some disease-modifying agents, such as methotrexate, have proved to be effective in slowing down or sometimes even reversing the progression of the disease (Canosco, 1997).

The first sample (RA-1; N = 145) was initially recruited in 1984 and participants were in their 1lth wave of data collection at the time they were administered the G L H C items. Seventy-five percent of RA-1 participants were women, which is representative of the gender ratio in the disease population (Callahan & Rao, 1996;

Canosco, 1997; Schumacher, Klippel, & Koopman, 1993). A t the time they filled out the G L H C, they had been diagnosed with R A, on average, for approximately 12 years and averaged slightly more than 60 years of age. Ninety-five percent of RA-1 participants were European American. The second sample of persons with R A (RA-2; N = 163), was recruited in 1992. Participants in RA-2 were in their second wave of data collection when the G L H C was administered. Seventy-one percent of RA-2 participants were women, and 91% were European American. A t wave two, participants in RA-2 averaged 56 years of age and had been diagnosed with R A for an average of 4 years. The majority of participants in both RA-1 and RA-2 lived in the middle Tennessee area.

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System ic Sclerosis This sample consisted of 93 individuals with confirmed diagnoses of SSc. SSc is a severe, chronic, and progressive rheumatic disease characterized by the thickening and hardening of the skin, which may sometimes extend t o other organ systems. Progression of the disease is unpredictable, and only palliative treatment is available. Significant mortality is associated with the disease if the skin thickening affects the trunk (Medsger & Steen, 1996).

Participants were recruited from patient lists a t the medical centers of the University of California, Los Angeles, and the University of California, San Diego.

They averaged 50 years of age and had been diagnosed with SSc for an average of 5 years. Eighty-six percent of participants were women, which is representative of the gender ratio in the disease population (ratio of women to men is approximately 4:l; Steen, 1990; Steen & Medsger, 1990). Sixty-nine percent of participants were European American, 12% were Hispanic American, 8% were African American, 4% were Asian American, and 7% represented other groups.

Measures Demographics For both groups, demographic information was collected via self-report questionnaire. Information collected included date of birth, sex, marital status, number and age of children, occupation, highest level of education completed, annual family income, and ethnic background. The participants with R A responded to a threeitem measure assessing how important their religion was to them (coefficient alpha =.87 {RA-1) and.85 {RA-2)). The SSc participants were asked for their religious affiliation and whether they actively practiced their religion.

Perceptions o f Control For all participants, the 18-item Form C of the M H L C scales was used. This self-report instrument assesses the extent to which participants believe their condition (i.e., R A or SSc) is due to: (I) their own behavior (internality); (2) the behavior of doctors; (3) the behavior of other people, not including doctors; and (4) chance, luck, or fate. Form C of the M H L C has been thoroughly tested and has been shown to have adequate psychometric properties (Wallston e t al., 1994). Subscales from Form C predictably relate to changes resulting from an intervention program (Sinclair eta]., 1998), to other measures of perceived control (e.g., arthritis helplessness), and to health-related criteria such as pain, functional impairment, and depression (Wallston e t al., 1994).

All participants also completed the newly developed God Locus of Health Control (GLHC) scale. The G L H C scale represents a new dimension of the M H L C scales and shares the same format. The six items constituting the G L H C scale can be found in Table I. The G L H C scale can be used alone or incorporated within the M H L C scales, as was done in these studies. Reliability and validity data for the G L H C is presented in the Results section.

God Locus of Health Control Table I. God Locus of Health Control (GLHC) Items If my {condition} worsens, it is up to God to determine whether I will feel better again.

The shortened VPMI consists of a five-item subscale assessing active pain coping and a six-item subscale assessing passive pain coping. With the exception of two VMPCI subscales (stoicism and self-blame), all of the pain-coping subscales had acceptable levels of reliability (Smith e t al., 1997). Although the validity of the VPMI has been well established (Brown & Nicassio, 1987), Smith e t al. (1997) report that the VMPCI has incremental validity over the VPMI in predicting impairment, physical functioning, and psychological well-being.

Vitaliano, 1991) was administered to the SSc sample. The WCCL-R is a 57-item self-report instrument that assesses cognitive and behavioral coping within the context of an identified stressor. For this study, participants used a 4-point scale to indicate the extent to which they used each of the described strategies to cope with their medical condition. The WCCL-R yields a three-item subscale assessing the use of religious coping (alpha =.71) plus seven other coping subscales (problemfocused, wishful thinking, seeking social support, avoidance, self-blame, blaming others, and counting one's blessings). The subscale s have acceptable reliability and concurrent and construct validity, and low interscale correlations. For the present sample internal consistencies for the subscales ranged from.67 to.84. The WCCL-R has been validated for use with SSc in a previous study (Malcarne & Greenbergs, 1996).

Psychosocial Outcomes As with coping, different measures of psychosocial outcomes were administered to the RA and SSc samples. Both yield validated negative affectivity constructs.

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